media form .pdf

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Original filename: media_form.pdf
Title: Student Media Release Form
Author: User

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Student Media Release Consent Form

Form 529B
Revised Jun 15, 2010

Please ensure one box is checked for Part 1 and one box is checked for Part 2 of this form.

Part 1– Events
I, _____________________________________________, hereby agree and give my permission for the Toronto
(Name of parent/guardian if student is a minor, under the age of 18.
Name of student if an adult, 18 years of age or older.)

District School Board and/or partners to record, film, photograph, audiotape or videotape my/my child’s name,
image, student work, and performance (hereinafter collectively referred to as “Works”) and to display, publish or
distribute these Works for the purpose of publishing, posting on the TDSB website, posting in schools, posting on
social media sites and/or for broadcasting on television or radio as determined by the TDSB.
I hereby waive any right to approve the use of these Works now or in the future, whether the use is known to me or
unknown, and I waive any right to any royalties related to the use of these Works.
I understand that the Works may appear in electronic form on the internet or in other publications outside of the
TDSB’s control. I agree that I will not hold the TDSB responsible for any harm that may arise from such
unauthorized reproduction.
Pl Please mark this box if you AGREE that your child may participate in recorded TDSB/school events and TDSB
hosted events as described above. (See Part 2 below)
Please mark this box if you DO NOT WISH your child to participate in recorded TDSB/school events and
TDSB hosted events.

Part 2 – Media Specific
I also understand that external media organizations may attend school events. I give permission for my/my child’s
name, image, student work, and performance to be photographed, filmed, audio-taped or videotaped for the purpose
of being published and/or broadcast on-line, on television or radio.
Please mark this box if you AGREE that your child may participate in media events that may be published or
broadcast by organizations external to the Toronto District School Board.
Please mark this box if you DO NOT WISH your child to be photographed, filmed, audio-taped or videotaped
at media events.

I have read this Student Media Release Consent Form and I fully understand the contents and meaning of this
release. I understand that I am free to contact the Principal with any questions regarding this release.

Student’s Name: ____________________________________________________________
School:
Student’s Signature (If 18 years of age or older)
Parent’s/Guardian’s Name:
Parent’s/Guardian’s Signature (If student is a minor – under the age of 18):
Date:

G02(R:\Secretariat\Staff\G02\03\OP\FORMS\529B.doc)sec.1530

Grade: ___


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